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. 2025 Dec 15;25(1):4253.
doi: 10.1186/s12889-025-25571-2.

Recurrent myocardial infarction and adherence to secondary prevention strategies among adults with coronary artery disease in rural Aluva, South India: a nested case-control study

Neeraj Vinod Mohandas  1   2 , Vijayakumar Krishnapillai  3   4 , Neethu George  5 , Avani Dinesh  3   6 , Vinod Mohandas  7
Affiliations

Recurrent myocardial infarction and adherence to secondary prevention strategies among adults with coronary artery disease in rural Aluva, South India: a nested case-control study

Neeraj Vinod Mohandas et al. BMC Public Health. .

Abstract

Background: Recurrent myocardial infarction (re-MI) remains a significant challenge in cardiovascular care, especially in low-income countries. Despite advancements in cardiac care, many patients with coronary artery disease (CAD) fail to follow the secondary prevention guidelines consistently. This study aims to determine the independent predictors of re-MI and inadequate adherence to secondary prevention strategies among adults with CAD in a rural cohort in South India.

Methods: A nested case-control study with risk set sampling of controls was conducted from January 2022 to March 2022 within the ENDIRA (Epidemiology of Non-communicable Diseases In Rural Areas) Cohort in the rural part of Aluva municipality of Ernakulam district, Kerala, India. CAD patients aged 35-80 years from the ENDIRA cohort who have had one or more episodes of myocardial infarction 28 days post the index episode as confirmed by medical reports were selected as cases while those with no recurrent episodes were taken as controls. Descriptive analysis was conducted to characterise the study population and was expressed in frequencies and percentages. Regression models were used to determine the independent predictors of re-MI as well as inadequate adherence and was expressed using adjusted odds ratio along with 95% confidence intervals.

Results: The study included 187 cases and 436 controls. The independent predictors of recurrent myocardial infarction included poor socio-economic status (Adjusted Odds Ratio [AOR] 1.98; 95% confidence interval [CI] 1.34-2.91), > 5 years since CAD diagnosis (AOR 1.53; 95% CI 1.06-2.22), previous history of CABG (AOR 1.75;95% CI 1.17-2.61), alcohol consumption (AOR 1.65; 95% CI 1.04-2.61), follow up under complementary and alternative medicine (AOR 2.04; 95% CI 1.03-4.01), distance to follow up hospital > 20 kms (AOR 1.85; 95% CI 1.09-3.12) and uncontrolled blood pressure (AOR 1.60; 95% CI 1.07-2.39). The CAD patients preferring private facilities for follow up were 43% less likely to develop recurrent myocardial infarction. (AOR 0.57; 95% CI 0.34-0.95).

Conclusion: The determinants of recurrent myocardial infarction and inadequate adherence are multifactorial, encompassing socioeconomic, behavioural and health system factors. Strengthening equitable access to quality secondary prevention services, integrating social support, and improving continuity of cardiac care are essential to reduce recurrence and improve outcomes in rural India.

Keywords: CAD; MI; Non-adherence; Preventive cardiology; Re-MI; Secondary prevention.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Ethical clearance was obtained from the Ethics Committee of Amrita School of Medicine prior to the commencement of the study (ECASM-AIMS-2021–143) in accordance with the Declaration of Helsinki. The patients/participants provided their written informed consent in the local language (Malayalam) to participate in this study. The consent included the title of the study, purpose, benefits and the right to not participate in the study if he/she does not wish to. Throughout the course of the study, confidentiality of the participants was maintained. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
STROBE Flowchart
Fig. 2
Fig. 2
Development of the assessment tool for adherence to secondary prevention strategies-Delphi consensus method
Fig. 3
Fig. 3
Adherence to secondary prevention domains in cases and controls
Fig. 4
Fig. 4
Final Regression model predicting the independent factors of recurrent myocardial infarction
Fig. 5
Fig. 5
Independent predictors of inadequate adherence to secondary prevention strategies in recurrent myocardial infarction (N = 187)
See this image and copyright information in PMC

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